Lean in healthcare – history and recent developments

Lean in healthcare – history and recent developments

Article Type: Guest editorial From: Journal of Health Organization and Management , Volume 28, Issue 2

Continual pressures on healthcare budgets coupled with increasing demands (Institute of Medicine, 2012; OECD, 2002; Porter and Lee, 2013) and evidence of poor performance have led national and local healthcare organizations to look for methods to improve quality, safety and value in health service delivery. Increasingly this search for solutions has extended beyond the boundaries of healthcare practice to investigate methods that have been successfully employed in other industries. Lean Systems Thinking (LST) and continuous improvement activities have come to the attention of healthcare administrators looking for ways to improve organizational performance. Originating in the work of Deming (1953), and refined in Japan, lean techniques and lean management principles have been developing in manufacturing settings since the 1950s. After becoming prominent in the early 1980s, lean practices have more recently been introduced into service industries.

In both manufacturing and service contexts lean implementation has concentrated on identifying value-adding processes and removing waste from the system. While healthcare provision and manufacturing operations may differ in many ways, the prerequisites for successful change in each have been found to be remarkably similar – demonstrated commitment to the projects from senior management, engagement of the practitioners involved and recognition of shop floor expertise in the identification of possible improvements. Their differences in terms of the geographical protection of healthcare delivery, the variability of customer presentations and the high specialist influence in healthcare only add to the contingencies that need to be considered in the adoption of lean techniques into healthcare organizations. Though healthcare organizations are inherently conservative, the utilization of LST and activities in healthcare is now gaining increased attention.

Prior applications of lean in healthcare have focused on improving the safety, quality and efficiency of healthcare delivery in areas such as improving information and communication flow, the delivery of innovations to drive continuous service delivery improvement, redesigning the patient journey to improve access and reduce waiting times, medical supply chain management, implementation of IT solutions and policy implications ranging from the local organizational level to decisions on national healthcare policy. Lean is being implemented in both large health institutions and across national health systems. Lean initiatives have been found to have positive impacts on timely delivery of services, cost, quality and healthcare productivity. The introduction of lean into the highly complex health service sector with its varied professional identifications has highlighted the influence of the socio-technical aspects of lean implementation – the major focus of the papers in this special issue. The papers in this issue seek to uncover factors that facilitate the acceptance of LST in healthcare.

Several papers in this special issue, in particular Drotz and Poksinska (2014) and Timmons et al. (2014), allude to an important question involving the mechanism leading clinicians to accept and implement LST in healthcare organizations. Healthcare organizations are acknowledged to be difficult contexts in which to enact change (Nembhard et al., 2009), populated by powerful and semi-autonomous professional groups (Timmons et al., 2014), and presenting dramatically different contexts to the car manufacturers where LST originated. However, a well-researched mechanism to explain the acceptance of LST in health exists grounded in the experimental learning literature of psychology.

One important question involves the mechanism leading clinicians to accept and implement lean philosophy and tools in healthcare organizations. Delays, duplicated information, rework, staff-burnout, unnecessary movement of patients and staff, missing equipment and supplies are endemic and enduring features of healthcare organizations. People working in healthcare organizations become skilled in developing “workarounds” (Tucker et al., 2013) but the eight wastes categorized by LST (over-production, transportation, waiting, over-processing, motion, inventory, defective products and latent talent) cause organizations and individuals pain, dissatisfaction and frustration. LST provides opportunities for people in healthcare organizations to reduce some of their own, workplace-inflicted pain, in autonomous ways consistent with their professional and occupational norms. In reducing any of the eight wastes healthcare organizations are changing their working environments in ways that deliver welcome, negative reinforcement to their staff.

Operant conditioning (Skinner, 1976) identifies four ways to modify behaviour through pairing a stimulus with a response. Possibly the most misunderstood is negative reinforcement, in which a behaviour is paired with the removal of an aversive stimulus, resulting in an increased frequency of the behaviour, e.g. rapid acceptance of effective migraine medication (Treisman and Clark, 2011). Successfully using LST to remove one waste in a healthcare organization may well lead to increased efforts to address other causes of organizational pain.

To date much lean health literature has focused on results achieved; however, as reported in the papers included in this special issue, individual and social factors are now receiving consideration. The spread of safety, quality and value improvements in healthcare organizations may proceed more quickly in the next decade if all healthcare organization members are given the opportunity to reduce the pain they experience, and in doing so reduce the pain experienced by their patients.

The first paper in this special issue by Al-Balushi et al. (2014) forms an introduction to lean in healthcare by presenting a comprehensive review of the literature on lean and lean healthcare. Along with the established readiness factors of leadership, organizational culture, communication, training, measurement and reward systems that have previously been established in the general management literature as necessary for successful change management they further identify the ability to authorize a decentralized management style, and to undertake an end-to-end process view as critical for the successful application of lean operating principals in healthcare organizations.

After this introduction to the historical development of lean in healthcare Morrow et al. (2014) develop this theme through an examination of the nature and impact of leadership in lean implementation. In their examination of 13 NHS case studies they found that leadership at multiple levels was necessary for effective lean implementation. For this leadership to be successful development of lean skills and knowledge, along with the empowerment of team members, was a prerequisite to implementation at all levels. It was further recognized that there was no one “best practice” leadership style, but that different approaches must be developed to match the traits of individual leaders.

The work of Morrow et al. (2014) is re-enforced by Drotz and Poksinska (2014) who examined lean implementation from the employee's perspective. They interviewed the professionals in three healthcare organizations with varying approaches to implementing lean, examining how lean production influences the roles, responsibilities and job characteristics of the healthcare professional. While not all aspects of lean were transferred successfully into the healthcare sector, for example increased multiskilling and job rotation were seen as unsuitable for application in the healthcare context. However, significant improvements were seen through the adoption of standardization, flow orientation, improvement team rotation and the implementation of visual controls, though the existing power structures within healthcare moderated the full realization of the benefits that could be obtained from lean implementation. Drotz and Poksinska (2014) highlighted the importance of team functioning, and the implementation and group functioning of healthcare teams has been examined by Ulhassan et al. (2014). Their study examining the socio-technical aspects of a lean intervention explored the changes that arose in teamwork over time related to a lean intervention in a Swedish hospital. Their longitudinal study into team functioning in three departments revealed varying impacts of lean on teamwork, which they primarily attributed to the group functioning at the time when lean is initiated, indicating that successful lean implementation is more likely if it is built on well-established, functional work teams.

A further study by Timmons et al. (2014) of the implementation of lean methods in an emergency department investigated role of the professions and professional status in the success of lean implementation. They found the status of the professional project for doctors in the Emergency Department lead to more engagement and enthusiasm by the professionals than is usually reported in the literature on lean implementation in healthcare, indicating the acceptability of initiatives like lean methods in healthcare may be heavily influenced by the professional status of the participants. The work of Hayes et al. (2014) reinforces the findings of Ulhassan et al. (2014) and Timmons et al. (2014) in also emphasizing the importance of mutual recognition of participants’ expertise in an effective lean rapid improvement event. While detailing the mechanisms of a rapid improvement event, their report also quantifies the significant benefits that may arise through trusting the occupational expertise of the participants to solve their own problems. It also demonstrates the applicability of lean techniques between as well as within emergency and pathology hospital departments. Along with the quantifiable improvements in process times, LST supported a calmer working environment, and personnel reported increased satisfaction through their exercising control over their work environment.

While the previous studies report on the implementation of lean methodologies in individual departments or projects, the final two papers in this special edition report on system level implementation of lean techniques. In their comparison of Australasian healthcare supply chains with those of the European automotive industry, Tillmann et al. (2014) found these supply chains were generally underperforming. An exception was found in an organization that had elevated supply chain management to a core competence for their organization. There a systems approach including mapping value stream performance had increased functional integration of the supply chain, with consequent increases in performance.

The paper that concludes this special edition is the work of Mazzocato et al. (2014) who undertook multiple case studies to examine the impact of a hospital-wide lean inspired intervention on independent organizations in their supply chain, and reciprocal effects on hospital performance. As with the interventions examined in single departments, Mazzocato et al. (2014) study emphasized the critical role of leadership in lean implementation and further identified that care process complexity may be a significant source of variation in the success of implementing lean process improvements. In complex care processes the ability to coordinate across inter- and intra-organizational boundaries was found to be integral to achieving improvements in process capability.

The papers in this issue, as well as many other published articles reflect once again the impact lean, LST and associated approaches can have on a healthcare system. The papers indicate the importance of not only the tools and techniques but the organizational factors that are important to implement and sustain the lean approach. However, as Radnor et al. (2012) reported lean is context specific and some of the assumptions that hold with the implementation of lean in manufacturing organizations do not hold in healthcare systems. Challenges of defining the customer and the subsequent creation of customer value; disjointed approaches to implementing lean; tool-based approaches being taken and implementations projects tended to “hit a glass ceiling” were reported (Radnor et al., 2012). The good news is, as the findings of the papers in this issue report, aspects of these are being addressed. This is important given the need for healthcare organizations and networks to remember, manage themselves and delivery with service at its core. Designing and improving processes and systems to delivery service-based healthcare is critical to meet the needs and expectations of the citizen. Engaging in LST supports this but LST itself must be continually challenged for both practice and theory to be developed.

Terry Sloan
University of Western Sydney, Sydney, Australia
Anneke Fitzgerald and Kathryn J. Hayes
Griffith University, Southport, Australia
Zoe Radnor
Loughborough University in London, London, UK
Suzanne Robinson
Curtin University, Perth, Australia
Amrik Sohal
Monash University, Melbourne, Australia

References

Al-Balushi, S., Sohal, A.S., Singh, P.J., Al Hajri, A., Al Farsi, Y.M. and Al Abri, R. (2014), “Readiness factors for lean implementation in healthcare settings – a literature review”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 135-153

Böhme, T., Williams, S., Childerhouse, P., Deakins, E. and Towill, D. (2014), “Squaring the circle of healthcare supplies”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 247-265

Deming, W.E. (1953), “Statistical techniques in industry”, Advanced Management, Vol. 18 No. 11, pp. 8-12

Drotz, E. and Poksinska, B. (2014), “Lean in healthcare from employees’ perspectives”, Journal of Health Organization and Management, Vol. 28 No. 2pp. 177-195

Hayes, K.J., Reed, N., Fitzgerald, A. and Watt, V. (2014), “Applying lean flows in pathology laboratory remodelling”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 229-246

Institute of Medicine (2012), Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, The National Academies Press, Washington, DC

Mazzocato, P., Thor, J., Bäckman, U., Brommels, M., Carlsson, J., Jonsson, F., Hagmar, M. and Savage, C. (2014), “Complexity complicates lean: lessons from seven emergency services”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 266-288

Morrow, E., Robert, G. and Maben, J. (2014), “Exploring the nature and impact of leadership on the local implementation of The Productive Ward Releasing Time to CareTM”, Journal of Health Organisation and Management, Vol. 28 No. 2, pp. 154-176

Nembhard, I.M., Alexander, J.A., Hoff, T.J. and Ramanujam, R. (2009), “Why does the quality of health care continue to lag? Insights from management research”, Academy of Management Perspectives, Vol. 23 No. 1, pp. 24-42

OECD (2002), Measuring Up: Improving Health System Performance in OECD Countries, Organisation for Economic Cooperation and Development Publications Service, Paris

Porter, M. and Lee, T.H. (2013), “The strategy that will fix health care: providers must lead the way in making value the overarching goal”, Harvard Business Review, Vol. 91 No. 10, pp. 50-68

Radnor, Z.J., Holweg, H. and Waring, J. (2012), “Lean in healthcare: the unfilled promise?”, Social Science and Medicine, Vol. 74 No. 3, pp. 364-371

Skinner, B.F. (1976), About Behaviorism, Vintage Books, New York, NY

Timmons, S., Coffey, F. and Vezyridis, P. (2014), “Implementing lean methods in the Emergency Department: the role of professions and professional status”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 214-228

Treisman, G.J. and Clark, M.R. 2011, “A behaviorist perspective”, in Clark, M.R. and Treisman, G.J. (Eds), Chronic Pain and Addiction, Advances in Psychosomatic Medicine, Vol. 30, Karger, Basel, pp. 8-21

Tucker, A., Heisler, W.S. and Janisse, L. (2013), “Organizational factors that contribute to operational failures in hospitals”, working paper, Harvard Business School Division of Research, Boston, MA, available at: http://www.hbs.edu/faculty/Pages/download.aspx?name=14-023.pdf

Ulhassan, W., Westerlund, H., Thor, J., Sandahl, C. and von Thiele Schwarz, U. (2014), “Does Lean implementation interact with group functioning?”, Journal of Health Organization and Management, Vol. 28 No. 2, pp. 196-213